Action Plans
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Action plans for different levels of the stepped care model
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Make space for people to connect with their cultural identity.
Involve whānau.
Acknowledge and normalise the psychosocial impacts of stroke.
Watch and wait: keep monitoring well-being through observation, conversation and team meetings.
Build therapeutic relationships, creating space for trusting relationships and on-going kōrero about well-being.
Focus on people’s strengths and strategies they have used successfully in the past.
Engage in goal-setting and problem-solving.
Provide information and education. Let people know where they can get support.
Support people’s existing social networks and help them connect with new social networks.
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Complete more comprehensive mental health screening and assessment
Provide psychologically-informed interventions such as Motivational Interviewing or Solution Focused Brief Therapy
Engage in goal-setting and problem-solving
Focus on people’s strengths and strategies they have used successfully in the past
Ensure adequate sleep, diet, exercise and fatigue management
Consult with psychology
Consider anti-depressants
Connect the person with psychosocial education groups
Provide details for on-going mental health support
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Refer for psychological or psychiatric assessment or intervention.
Monitor psychosocial risks and commence intervention as indicated.
Provide details for on-going mental health support.
Consider anti-depressants.
Ensure psychosocial needs are clearly documented as people move through stroke pathways, and provide information about how people can access specialist support as required.
Provide clear plans for supporting the patient once they are ‘sub- threshold’ (level one on the stepped care model).
Action plans to support psychosocial well-being
There are a number of things that can be done to support psychosocial well-being. Some of these apply for everyone and reflect a proactive, preventative approach to supporting well-being. Others are more specifically targeted depending on the extent and severity of the person’s needs.
Level 1:
‘Sub-threshold’ mood changes at a level common to many or most people with stroke
This can include normal expressions of grief and loss, stress, mood and anxiety, which are mild, fluctuate during the day and have little impact on engagement in rehabilitation and daily tasks. Note that support can be provided by whānau, peers and all of the multi-disciplinary team.
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Acknowledging the emotional impacts of stroke is valuable. Regardless of whether the person is currently experiencing any issues, knowing that this is common after stroke can help provide reassurance; it can also mean that people are not surprised if they have challenges later.
Continue to build and focus on therapeutic relationships. Whakawhiti kōrero: within interactions, continue to create space for care and discussion about the different impacts of stroke. The small connections can make a significant difference to people during a challenging time.
‘Watch and wait’: No immediate action required, but continue to monitor well- being via observation, conversation and multi-disciplinary team meetings.
Attend to how clinicians and the service demonstrate manaakitanga. Consider how people are welcomed as guests into the stroke services.
Build on people’s strengths. Explore how they have coped with stress or difficult situations in the past – what has helped, who has been able to provide supports?
Practice active listening – listen for what people say, what they don’t say, what comes through in their tone of voice or body language. Acknowledge this. Try and allow time for conversation so they don’t feel rushed and that they know you are interested in listening. Respond in ways that encourage them to keep sharing.
Normalise, don’t minimise people’s issues. Providing reassurance that their reactions are common is valuable. In doing this, signpost where people can get informal support, who they can talk to, and where further professional help can be found. The team can normalise the role of psychologists in supporting adjustment and rehabilitation.
Identify key whānau who should be involved in people’s care and keep conversations open with them. They often know their person best and know what is normal and not normal for them. They can help alert you to signs that the person might be struggling or might need additional support. Normalise things for them as well, and help them know how they can ask for support for their whānau member, and for themselves. Ensure that whānau are involved in decision-making if the person with stroke wishes.
Looking to the future, goal-setting, and seeing markers of progress is important in helping people feel a sense of progress, hope, and possibility. It also helps build a sense of competence. Talk about what matters to people – what brings them joy, meaning, and satisfaction. Find out why these things matter. Goal-setting should overtly orient to what is meaningful to people in their life beyond stroke. Building in indicators of progress helps people objectively see progress when it might be hard for them to feel that they are progressing.
Provide simple education and resources (verbal, written, and pictoral) for people about well-being and adjustment. Make sure this is reviewed before discharge.
Facilitating social supports and networks can help support well-being. Social networks often reduce after a stroke, particularly when the person has communication impairments. Working proactively to maintain existing relationships, and to help people develop new relationships (e.g. with others with stroke) can be helpful.
Provide culturally safe care.
If someone identifies a strong connection to a cultural identity, explore what is important for supporting them – for instance, spiritual practices, language, culturally-based approaches to healing (e.g. mirimiri, acupuncture) – and together consider how these might be supported in stroke services.
Level 2:
Mild to moderate psychosocial symptoms or difficulties that interfere with rehabilitation or daily tasks
This may include depressed mood, anxiety and panic, emotional lability, agitation, apathy or loss of motivation, which may contribute to sleep and appetite difficulties, and impact on their rehab and daily life.
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Further assessment by non-psychology stroke specialist staff, ideally with oversight/supervision by specialised stroke clinical psychologists or mental health clinicians. This should include an individualised review of the client’s current difficulties and history of mental health difficulties and treatment, discussion with client and whānau of their perceptions of their symptoms; and identifying relevant strengths, coping strategies and goals for supporting their psychological well-being.
MDT members with additional competence in psychological care can provide: Brief psychological interventions such as Motivational Interviewing, Solution Focused Brief Therapy, Take Charge. Many of these interventions have been adapted for people with post-stroke communication impairments.
Consultation and referral to psychologist if available. Clear pathways for referral to psychologists need to be in place and the stroke services need awareness of optimal utilisation of psychology services.
Provide advice and information to support adjustment, goal setting and problem solving
Draw on strengths: How do you normally cope with stress or with difficult situations in the past? What helps? Who can you draw on to support?
Ensure adequate sleep, nutrition, exercise, fatigue management and environment: e.g.,
Monitor diet and consider increased prompting and support as required.
Monitor sleep and provide information and support for sleep hygiene
Consider more structured fatigue management plan
Ensure regular exercise, adapted for client’s physical ability
Consider if the environment can be improved, e.g., more sunlight during day, less noise, better company, headphones and earplugs available
Antidepressant medication should be considered with clearly defined and accessible management plans to review or stop medication.
Consider referral to chaplain or cultural services
Actively encourage to attend psychosocial education groups if available, or consider developing these within your service. These groups may focus on issues such as grief, adjustment, or goal-setting.
Provide contact details for local mental health crisis numbers and Helplines to client and whānau. Some Helplines have texting options which can be easier for some clients with expressive language difficulties; services such as Relay can help people with communication difficulties connect with these mental health services.
Level 3:
Severe and/or persisting psychosocial difficulties which are diagnosable and require specialised intervention, pharmacological treatment and suicide risk assessment and for which treatments at Level 1 and 2 are not sufficient
These require the intervention of clinical psychologist, neuropsychologist and/or psychiatry, ideally with specialist expertise in stroke.
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Referral for further assessment and treatment. In the inpatient this might include inpatient psychologists or liaison psychiatry. Clear referral and triage pathways should be in place to prioritise urgent reviews. In the community setting this might include referrals to community mental health, psychologists within the community stroke rehabilitation team, GP referral to subsidised/free (only available to some GP clinics), or referral to private psychologists or psychiatrists.
Regular monitoring of psychosocial risks, for example expressions of self-harm, increased alcohol or substance use, relationship conflict or abuse, or self-neglect. If concerns, discuss these with client, whānau and team as appropriate. Only share pertinent information.
Provide contact details for local crisis and helplines to client and whānau. Some helplines have texting options which can be easier for some clients with communication difficulties.
Antidepressant medication should be considered with clearly defined and accessible management plans to review or stop medication.
Psychosocial needs should be considered in the ongoing management and collaborative care plan. Psychosocial needs for clients and whānau should be clearly communicated in transitions between service, e.g., in discharge reports, handovers and referrals. Include a route for ongoing support by stroke service teams or the voluntary sector once the patient is subthreshold
Develop and enhance relationships between mental health teams and the stroke service
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Creating an environment that supports well-being
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Development of psychosocial pathways in stroke services
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Psychosocial screening
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Action plans to support well-being
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Whānau well-being